Insurance Agents & Brokers Professional Liability Form
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231381 Rancho Viejo Rd, Suite 101, San Juan Capistrano, CA 92675
Phone (800) 488-4096 / (949) 488-2255
Fax (949) 488-2259
Insurance Agents & Brokers Professional Liability
1. Name of Agency:
Date Established:
2. Contact Name:
3. Phone:
Fax:
Email address:
4. Risk Address:
5. Mailing :
6. Number of years insurance agency experience:
Number of years continuous E&O coverage:
(If experience is less than 5 years, please attach resume)
7. Name of current E&O carrier:
Current Retro Date:
Policy Eff Date:
8. Limits and deductible currently carried:
Premium:
9. Please provide the following based on the last 12 months of operation:
Agency P&C Premium Volume $ __________________ Agency P&C Commission Income $ __________________________
Agency Life/ A&H Commission Income $ ____________ Variable Annuities $ ____________ Broker Fees $ ______________
10. The Applicant is: Individual ______ Partner _____ Corporation _____ Other (Describe) ___________________________
(including Owners, CSR’s, 1099, etc.) How many are sub-producers? (1099 producers) _______
11. Total Staff Size
Number of employees with professional designations (CIC, CPSR, CISR, CPCU, CLU):__________________________
Number of employees with at least 3 years experience: __________
12. Has the Applicant had any E & O claims in the past 5 years?
Yes
No
a
Has the Applicant been the subject of disciplinary action or investigation?
Yes
No
b
Does the Applicant have any knowledge of any potential E & O claim(s)?
Yes
No
c
Has the Applicant been declined, cancelled or non-renewed?
Yes
No
(If yes to any of the above please attach an explanation with details.)
13. Have any employees attended any E&O loss prevention seminars or other industry related education courses within the
past two years? _____YES
NO
Who Sponsored: PIA _______ Other ____________________
14. Any changes in Ownership or Acquistions in the past 12 months?
15. Percentage of business placed: Direct with carriers: _________ % MGA ______ % Wholesale: ______ % = 100%
16. Percentage of business Placed with Carriers:
Admitted: ________ %
Non-Admitted _______ % = 100%
17. List all carriers business is placed with, including those accessed via broker, wholesalers or MGA.
Insurance Company
Admitted
Volume Placed
Current “Best Insurance Rating”
Yes
No
Yes
No
Yes
No
Yes
No
18. Number of companies represented with B + or lower A.M. Best Rating:
19. Business you placed as an: Agent/Broker _____ % Surplus Lines ______ % MGA ______ % Captive Agent ______% = 100%
Rev. 05/23/2016
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